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This is the first installment of a 2-part commentary by Jones & Bartlett Learning author and health policy expert, Joel Teitelbaum, on the most recent challenge to the Affordable Care Act (ACA), now a case before the U.S. Supreme Court. The second installment will discuss the Supreme Court’s decision in the case (expected by the end of June, when the Court concludes its current term).

On March 4th, 2015, the United States Supreme Court held oral arguments in yet another case – the third since 2012 – concerning the legality, meaning, and/or operation of the Affordable Care Act (ACA). In King v. Burwell, the court is considering whether “the Internal Revenue Service [IRS] may permissibly promulgate regulations to extend tax-credit subsidies to coverage purchased through exchanges established by the federal government under Section 1321 of the Patient Protection and Affordable Care Act.” While seemingly dry and technical on its face, in fact the answer to this question will determine whether millions of low- and moderate-income Americans will continue to have access to affordable health insurance coverage. In this blog post, I describe the issue at the heart of King v. Burwell; in a later blog post, I will discuss the Supreme Court’s decision in the case (expected by the end of June, when the Court concludes its current term).

The background: The ACA directs states to create an insurance exchange – effectively, an online marketplace where individuals can compare and shop for health insurance policies for themselves and their families. Should a state decide not to set up its own exchange – and a whopping 34 states ultimately took that path – the ACA indicated that the federal government would fill the void by creating a “federally facilitated marketplace,” or FFM, in the state, thus allowing residents of a “non-exchange state” the opportunity to purchase affordable health insurance. Furthermore, the ACA offers federal tax credits (i.e., a subsidy) to individuals who need financial assistance in order to purchase products through an exchange. In establishing the formula used to determine the awarding of the tax credits, Congress wrote in the ACA that the credits apply to insurance purchased through an exchange “established by the State.” Put another way, the ACA’s language about the flow of tax credits to those who purchase insurance through an exchange does not specifically mention marketplaces that were established by the federal government to assist those individuals in “non-exchange states.”

After the ACA was passed and federal agencies began the task of passing thousands of rules implementing the law, the IRS issued a regulation indicating that tax credits were available for purchases under both state-formed and federally-facilitated exchanges. Subsequently, about 90 percent of the approximately five million people who purchased insurance through a federally-facilitated exchange received the ACA’s tax subsidy.

The plaintiffs who initiated King v. Burwell contend that the IRS regulation is unlawful. They argue that the statutory language “established by the State” means that ACA tax credits are allowed only in the event that the purchase of insurance occurred through an exchange established by a state. In contrast, those legislators who wrote the statute, and other supporters of the ACA, contend that when read as a whole, the ACA makes it clear that both state- and federally-run exchanges are subject to the law’s subsidy language.

Taken most simply – and least politically – Kingv. Burwell presents a straightforward question of statutory interpretation: How should the four words at issue be reconciled with the rest of the statute? This is hardly a novel question of law, as courts are routinely asked to interpret statutory ambiguities; and under existing Supreme Court precedent, courts are required to uphold regulations that reasonably resolve those ambiguities.

Two federal appellate courts – those courts that reside just below the U.S. Supreme Court – have already ruled on just what the ACA’s tax credit language means. As part of the King v. Burwell litigation, the Fourth Circuit Court of Appeals ruled, unanimously, that the subsidy language applies to state-based and federally-facilitated exchanges alike. In contrast, the D.C. Circuit Court of Appeals determined, in a 2-1 split decision, that ACA tax credits are limited to purchases made through federally-facilitated exchanges.

The stakes in King v. Burwell are incredibly high: If the Supreme Court sides with those challenging the IRS regulation and Congress does not subsequently amend the ACA to make clear that the subsidies apply to all exchanges (which is likely, given Republican disapproval of the ACA and the political logjam that exemplifies Congress), estimates put the number of adults and children who would become uninsured as a result at between 8 million and 10 million. Furthermore, insurance markets across the country would be likely to falter badly as a result of the destabilization that would occur from removing these millions of low-income but relatively healthy individuals from insurance pools.

Reading the tea leaves after Supreme Court oral arguments is risky, a fact about which we need look no further than the Court’s first ACA decision (in NFIB v. Sebelius), which defied nearly all expectations. That said, those hoping that a majority of the Court will employ a common sense, contextual reading of the ACA’s subsidy language – as opposed to one that is literal and purely textual – came away from the arguments with reason to hope. Of particular import, Justice Anthony Kennedy – oftentimes a key swing vote in the Court’s social policy jurisprudence – seemed concerned that by following the logic of the challengers, the ACA would be read to either coerce states into creating an Exchange or accept the fact that in not setting up an Exchange, they would face near-certain destruction of their insurance markets.

Joel Teitelbaum, JD, LLM is an Associate Professor and the Vice Chair of Academic Affairs in the Department of Health Policy at the George Washington University School of Public Health and Health Services. He also serves as Managing Director of the School’s Hirsh Health Law and Policy Program. Along with co-author Sara Wilensky, Professor Teitelbaum is the author of Essentials of Health Policy and Law, Second Edition from Jones & Bartlett Learning. (Qualified instructors are invited to request review copies here.)

Written for an introductory forensic science course, the updated Third Edition includes all-new and expanded coverage of crime lab procedures. It ties recent high profile crimes such as the capture of the “Grim Sleeper” serial killer and terrorist attacks, such as the Boston Marathon bomb to the forensic work that has been done to apprehend these criminals.

Here is what one instructor had to say about the book:

“I am not an expert in this field, however as a digital forensics specialist, I need to have the knowledge of forensic science and [Criminalistics: Forensic Science, Crime, and Terrorism, Third Edition] has helped me to achieve that. I would like to thank the author for this great book and the way he made it simple for any reader to understand. I found it fascinating and I will recommend this book to anyone who is interested in forensics science.”

When asked about her leadership qualities and motivations for seeking the presidency, Lund said that:

“For the past 5 years I have had the privilege of serving as the Department Chair of Kinesiology and Health at Georgia State University. In my role as chair, I have managed a budget, evaluated personnel, honed my communication skills, and sought ways to promote our department across the college and university and with the community surrounding Georgia State.

In my outreach endeavors, I have found that the physical education profession has much to offer, but until others understand what we are about, they often miss the potential connections. My continual advocacy for the department has led us to some interesting partnerships.

I have learned that there are often multiple ways to address a problem and that by involving the thoughts of others, there is increased buy in and willingness to compromise. My years on the NASPE Board were an immense help in preparing me for my current role of department chair as we worked as a team to solve problems and brainstorm new ideas to help build and brand the association.”

Created around the 2014 National Standards for Physical Education for K-12 education, Standards-Based Physical Education Curriculum Development, Third Edition is written by experts with a wealth of experience designing and implementing thematic curriculum. This innovative resource guides readers through the process of writing dynamic curriculum in physical education.

The text begins by looking at the new national standards and then analyzes physical education from a conceptual standpoint. From there, it goes on to examine the development of performance-based assessments designed to measure the extent of student learning and explores the various curricular models common to physical education. The Third Edition also delves into sport education, adventure education, outdoor education, traditional/multi-activity, fitness, and movement education, describing each model and how it links with physical education standards.

In 2015, Kay Perrin, PhD, MPH, joined us as a guest blogger for a series of five blog posts on the topic of the exciting new career field of the Health Navigator. This is the second of five.

In the first blog, I introduced the concept of the role of Health Navigators. In this second blog, I expand this conversation to include some valuable characteristics of Health Navigators as well as the need for internships within their training. Before jumping into required internships, let’s step back and explore some personality traits desired in Health Navigators. When seeking a fulfilling career as a Health Navigator professional, students may assess if they have a desire to serve as a patient advocate, if they have an aptitude for attention to detail, and if their life experience allowed for the development of empathy.

First, whether they are called community health workers, patient navigators, health insurance navigators, or a growing number of other job titles, Health Navigators, serve as a liaison between patients, caregivers, and their health care providers. It is essential that they work as advocates within the complex health care system to improve patient care. Health Navigators are one additional piece of the health care puzzle that attempts to catch patients’ problems prior to falling through the cracks. Therefore, whenever a member of the health care team identifies an issue, every team member needs to listen so the details are not ignored. Although there will be an educational level gap between physicians, nurses, social workers, dieticians, health navigators, and other members of the health care team, the Health Navigators work to investigate problematic situations to find plausible solutions.

Health Navigators serve as effective and persuasive advocates for patients and their caregivers. For example, a Health Navigator works with the discharge physician, nurse, and social worker by conducting a home visit prior to discharge to evaluate wheelchair accessibility, height of bed, and bathing options. This evaluation is not a home health assessment (e.g., wound care or administration of intravenous medications), but rather a holistic approach for the patient and the caregiver with emphasis on a safe recovery at home with the tools and support needed or incurring a readmission due to lack of knowledge and support or an unintentional injury.

Second, Health Navigators do not merely follow written medical orders or prescriptions, but rather they approach each situation with a holistic approach. For instance, if a patient’s follow-up medical visit is scheduled for three days after discharge, the Health Navigator needs to ask the patient and caregiver a few questions to ensure that keeping the appointment is possible rather than merely assuming that the patient will arrive on the given date and time.

Who will be driving you to the follow-up appointment?

Will your driver be able to lift and fit your wheelchair into the car?

Is your driver available when your appointment is scheduled?

…and many more similar questions.

If the Health Navigator asks these or other appropriate questions, there is a higher probability of appointment compliance. On the other hand, without a Health Navigator, the time and date of the appointment is given to the patient during discharge with the expectation of agreement. However, without asking specific questions, the unresolved issues prevent compliance with a follow-up appointment. These types of simple questions ensure that the patients and caregivers have complete understanding of appointments, medications, wound care, treatment plans, etc. for utmost compliance through reduction of barriers and lack of understanding.

Third, Health Navigators need the quality of empathy rather than sympathy. A sympathetic Health Navigator shares the feeling of the person suffering from the bad news or sad feelings. An empathic Health Navigator focuses on trying to understand or vicariously experience the sad feelings from a past personal event rather than feeling sorry for the person. For example, the Health Navigator might remember the sad feeling when his or her grandparent died, but would not attempt to share in the experience. The attribute of empathy is acquired through personal experience across the lifespan. An empathic Health Navigator knows to ask simple questions to move the conversation forward towards purposeful action or resolution.

With these qualities in mind, let’s explore the proposed curriculum and training described in the Community Colleges and Public Health Report. With expert input and years of discussion, this report recommends that all health navigators as well other public health students at the associate degree level complete the following courses:

Population and Personal Health

Overview of Public Health

Health Communications

In addition, Health Navigator students should complete the following courses:

Prevention and Community Health

Healthcare Delivery

Health Insurance

Health Information

Along with the course requirements, there are nine semester hours of electives.

In this blog, I would like to put forth the notion of incorporating a required paid internship into the nine hours of electives. After years of working with undergraduate students, I have observed that most students fall into one of two categories. Either they are locked into a career path and have limited interest in exploring other options or they are seeking a diploma with limited exploration of career choices. Neither of these common scenarios works for the evolving field of Health Navigators. First, since the concept of Health Navigators is unfamiliar, students are not likely to know what the career entails. Second, if students do not have personal or employment experience with health care providers, patients, and caregivers, they are less likely to visualize a holistic approach of care. For these and many more reasons, it is essential that future Health Navigators obtain internship experience during their degree program; otherwise, it is improbable that they will obtain employment upon graduation. In addition, these internships must offer a modest stipend for several reasons.

For the students, the internship stipend focuses the responsibility on being a future health care team member rather than being a hospital volunteer. This mindset encourages professional workforce development skills, e.g. appropriate attire, time management, and communication skills. On the hospital side, the financial commitment of paid internships introduces the concept of Health Navigators into the hospital workforce; forms strong links between community college and local hospitals; and allows hospitals to make a financial commitment to the development and employment of Health Navigators as a way to reduce ACA penalties associated with Medicare readmission rates. Lastly, for the community colleges, the paid internships provide positive recruitment strategies into the new Health Navigator degree; allows faculty to network with hospitals through the development of responsibilities of the student interns; and connects the classroom with the internship experience.

Ideally, the internship would not be a culminating experience during the last semester, but rather one 8-hour shift per week in the hospital for two semesters. Therefore, as the students gain knowledge and understanding in the classroom, they would experience higher levels of critical thinking in their hospital internship. Yes, of course, this paid internship concept is expensive and time-intensive for hospitals, community colleges and students. However, without a serious commitment at all levels, Health Navigators will gain academic knowledge and receive diplomas, but may not secure employment. Their employment is based on creating and demonstrating the need for Health Navigators to become a profession, a valuable, cost-saving member of the health care team.

—Kay Perrin

Kay Perrin, PhD, MPH, is an Associate Professor and Assistant Dean for the Office of Undergraduate Studies at the University of South Florida, College of Public Health. Dr. Perrin’s research focuses on adolescent health with a special interest in teen pregnancy. Dr. Perrin also serves on several community boards in the Tampa Bay Area. Dr. Perrin is the author of three titles from Jones & Bartlett Learning: Principles of Evaluation and Research for Health Care Programs, Essentials of Planning and Evaluation for Public Health (both published in 2014), as well as a forthcoming introductory Health Navigator textbook, available in late 2016. Follow Kay Perrin on Twitter @KayPerrinPhD or watch a webcast of Dr. Perrin’s October 2014 Webinar on Teaching Health Research, Program Planning, and Evaluation.

Further grounding this text in its emphasis on employment in the biotechnology industry, it provides real-world information on molecular techniques, regulations, and bioethics. It also features a Focus on Careers box in every chapter that provides critical information on type of education and competencies required to practice in the biotechnology industry.

To assist the reader in understanding key molecular biology concepts and processes, every new printed text is packaged with access to the Navigate Companion Website where students will find full-color animations and Lab Exercises.

Excellent news to share– Mastering Leadership: A Vital Resource for Health Care Organizations by Alan T. Belasen, Barry Eisenberg, and John W. Huppertz recently received a perfect score of 100 and 5 stars from Doody’s Review Service. According to reviewer, Cynthia Lee Cummings, RN, MSN, EdD, from the University of North Florida Brooks College of Health, it “provides valuable information to those interested in healthcare leadership and management.”

Read more excerpts from the review:

“The book deals with becoming an effective master leader. The authors incorporate the CVF and four main domains — communication and collaboration, competition and commitment, coordination and compliance, and community and credibility. They discuss the important topics of performance management, patient satisfaction, and strategic planning. The case studies and the review questions that are incorporated throughout are the best features.

I enjoyed this book. The authors provide a new concept with CVF, and the realistic and timely case studies provide an opportunity for important questioning and student interaction. The Affordable Care Act, marketing strategies, and technology are just some of the topics the book covers. It is well done and resourceful.”

“This comprehensive book presents all of the major nursing theories and discusses the philosophy of science and the foundations of knowledge development. An essential component focuses on the integration and dissemination of knowledge in advanced practice nursing.

The purpose is to provide both masters’ and doctoral students with a comprehensive reference that discusses the major nursing theories. It addresses the philosophy of science and clearly discusses the foundation for knowledge development. These objectives are extremely important to forwarding the nursing profession and the authors do an excellent job in meeting them.

The book is well organized, clear, and concise in its discussion of complex nursing theories and concepts. Additionally, it provides important bridges from the AACN’s DNP Essentials to specific nursing theories. This update was necessary to incorporate collaborative patient care, which is a cornerstone of healthcare today.”